Asian Americans are the highest-income,
best-educated and fastest-growing ethnic group in the U.S., according to a Pew
Research Center report released in 2012, called “The Rise of Asian Americans.”
When it comes to cosmetic treatment in this patient population, successful
outcomes may depend on understanding physiological and cultural nuances.
Washington, D.C., area dermatologist Hema
Sundaram, M.D., has a special interest in Asian aesthetics. She is lead author
of a new consensus group publication that will be published this spring in
Plastic and Reconstructive Surgery, which includes a discussion of injectables
treatments in Asians and other ethnicities. This article, "Global
Aesthetics Consensus: Hyaluronic acid fillers and botulinum toxin type A:
Recommendations for combined treatment and special considerations to optimize
outcomes in diverse patient populations," provides recommendations from a
notable group of dermatologists and plastic surgeons from the U.S., Canada,
Europe, Asia, Australia and Latin America. Joining Dr. Sundaram, the North
American faculty includes Drs. Jean Carruthers, Steven Fagien, Gary Monheit,
Rod Rohrich and Arthur Swift.
Dr. Sundaram says that dermatologists and
plastic surgeons in the U.S. will likely be treating increasing numbers of
Asian patients.
“This reflects ongoing expansion of the Asian
population in America, and the steady increase, year by year, in the number of
patients of color who seek cosmetic procedures, as revealed by annual
procedural surveys from the American Society for Dermatologic Surgery, American
Society for Aesthetic Plastic Surgery and other core aesthetic specialty
organizations,” she says.
Dr. Sundaram’s first recommendation for
cosmetic surgeons treating patients of all ethnicities: Focus on facial
harmonization, rather than rejuvenation.
“This entails age-appropriate modification of
congenital baseline characteristics, together with correction of acquired
disharmonies, which are usually age-related in our patients seeking cosmetic
procedures, although they can have other causes, such as injuries,” she says.
‘Typical’ Beauty Strategies
Cosmetic clinicians treating Asian patients
need to distinguish among ethnic populations, realizing the notable differences
between Caucasian and Asian faces and reflecting on cultural disparities, as
well as “distinctive treatment goals,” according to consensus recommendations
by the multi-specialty Asia-Pacific Consensus Group. Dr. Sundaram was a member
of this group, which developed consensus recommendations for Asians based on
members’ experiences using cohesive polydensified matrix hyaluronic acid and
calcium hydroxylapatite fillers. The group published its findings in November 2015
in Plastic and Reconstructive Surgery.
Taking that a step further, it’s important
for cosmetic surgeons to be aware of the typical congenital baseline for Asian
patients, but also to understand that Asian patients are not the homogeneous
population that some perceive them to be, according to Dr. Sundaram.
“Typical Asian strategies with injectables
include injection of filler to the medial midface, forehead and chin. Filler
may also be injected to the radix and dorsum of the nose. Botulinum toxin neuromodulator
is typically injected to the masseters,” Dr. Sundaram says.
Geographic variations reflect the significant
differences in facial canons and morphotypes between Northern-type Asians, such
as those from Korea and Japan, and Southern-type Asians, such as those from
Indonesia or Singapore, according to Dr. Sundaram.
“For example, augmentation of the medial
midface is not required for many Southern Asians, who already have sufficient
convexity in this facial region. However, they may have more requirement for
augmentation of the nasal bridge and dorsum, to correct concavities and produce
a narrowing effect,” she says. “Conversely, high doses of botulinum toxin to
the masseters may be more appropriate for Northern Asians, since their
congenital baseline tends to include a greater bimandibular width and a squarer
jaw.”
Arched eyebrows are not aesthetically
appropriate when there is a wider bimaxillary width, making a straighter
eyebrow more harmonizing for most Asian faces, according to Dr. Sundaram.
“This is currently a trend for many Caucasian
faces too,” she says. Dr. Sundaram has discussed aesthetic and procedural
considerations for the eyebrows and upper eyelids in a 2013 chapter for Clinics
in Plastic Surgery.
Facial
Analysis, Societal Ideals
Dr. Sundaram, who directs educational and
training programs focusing on Asian aesthetics and serves on scientific boards
of conferences in Asia, says ideals and canons of beauty have been traced
thousands of years back, to the Ancient Greeks.
“Originally, the canons were for Caucasian
faces, but now we have some publications for African and Afro-Caribbean faces,
[as well as] for Asian and for Indian. While an understanding of ethnic facial
canons is certainly helpful, we cannot get locked into these principles,” she
says.
An example Dr. Sundaram gave in a recent
lecture on the topic was to show images of two of her patients — one Caucasian
and one Asian. When she asked the audience if they saw similarities between the
two, everyone said no.
“I explained that I had actually injected
them with hyaluronic acid filler in a very similar way. The reason was that the
Caucasian patient inherently had many of the features that we see in Asian
faces. That was her congenital baseline, or starting point,” Dr. Sundaram says.
“She had a relative deficit of medial midface volume, and a retrusion of the
chin. Therefore, an ‘Asian-type’ injection strategy was appropriate to
harmonize her face.”
Facial analysis is more than
individualization; it’s also an awareness of societal ideals of beauty and
cultural overlays. An example of societal ideals is that an Asian growing up in
America is likely to have different aesthetic ideals than an Asian patient
growing up in Asia. To illustrate the concept, Dr. Sundaram points to the "charming
roll," an ideal which started in Korea with a celebrity who had tiny
volumes of hyaluronic acid filler injected just below the inferior ciliary
margin, to enhance the pre-tarsal orbicularis oculi bulge.
The aim, she says, was to give the celebrity
a wider-eyed appearance.
“This procedure has burgeoned in popularity
and is now very popular with Asian patients who have a relatively narrow
palpebral fissure and absence of the supratarsal crease,” she says. “If we
inject botulinum toxin too close to the inferior ciliary margin and obliterate
the pre-tarsal bulge, this can make patients who desire it and consider it a
hallmark of beauty very unhappy.”
On the other hand, second generation Asians
in the U.S. and other countries may be more influenced by the ideals of the
society in which they live — even preferring to reduce the prominence of the
pre-tarsal bulge. Similar variations in preferences exist for contour and
projection of the chin and forehead. Dr. Sundaram shares the example of a
half-Japanese, half-American female patient at her Washington, D.C., practice.
“She didn't like her pre-tarsal bulge as she
felt it made her look tired. She wanted her eyes opened up a bit with botulinum
toxin,” Dr. Sundaram says. “When we inject botulinum toxin to open the eyes, it
lowers the inferior ciliary margin by a fraction of a millimeter. But it takes
away the charming roll. So, that’s an example of the societal influence on
cosmetic preferences, and why we need to be well-informed about the nuances of
Asian aesthetics and having frank dialogues with our patients.”
Societal ideals have far-reaching cosmetic
effects. Another obvious example of societal influences is the longstanding
tendency for Asian women and some men to want to whiten or lighten their skin.
“They apply topicals for this purpose, and
may also sit in ‘whitening baths’ and take oral medications for that reason. In
contrast, Asian-Americans in the US and other Western countries don’t mind
having a tan, and may even seek to enhance their naturally tanned appearance,
like the rest of the population,” she says.
A Fundamental
Treatment Principle
As precise as Dr. Sundaram’s approaches for
treating Asian faces appear to be, she reiterates that individual
considerations must override generalizations.
“Migration patterns in Asia over millennia
have resulted in a great diversity of facial morphotypes in many Asian
countries,” she says. “The fundamental principle that I emphasize when
lecturing on and demonstrating injectables treatments for Asian patients is
that individualized treatment planning and implementation transcend ethnic
boundaries.”
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